415600965-4-29-2022-14-AS-CSMH-CMLVAL-20221230151608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600965
Report Date: 04/29/2022
Date Signed: 04/29/2022 07:18:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210618093002

FACILITY NAME:	OLIVIA'S CARE HOME		FACILITY NUMBER:	415600965
ADMINISTRATOR:	DE GUZMAN, OLIVIA		FACILITY TYPE:	740
ADDRESS:	2087 ISABELLE AVE		TELEPHONE:	(650) 345-3051
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Eva Zita and Olivia De Guzman		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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9

- Staff verbally abusive to residents

INVESTIGATION FINDINGS:

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13

LPA Jeung interviewed staff.

Based on information obtained by LPA Jeung from witnesses, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated.

LPA was advised that staff #1 is impatient wihen caring for clients, screams and yells, and described as having a bad temper, which was upsetting to client(s).

Deficiency of the CA Code of Regulations, Title 22 is cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20210618093002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLIVIA'S CARE HOME	FACILITY NUMBER: 415600965
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESIDENTS Residents in all RCFEs shall have the following personal right: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as LPA was told by a witness that client was subjected to	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE, which shall include remedial personal rights training for staff
	8 9 10 11 12 13 14	yelling and screaming by staff #1, which was upsetting to client(s). Licensee failed to ensure that clients were accorded dignity and respect in their relationship with staff, which poses a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210618093002

FACILITY NAME:	OLIVIA'S CARE HOME		FACILITY NUMBER:	415600965
ADMINISTRATOR:	DE GUZMAN, OLIVIA		FACILITY TYPE:	740
ADDRESS:	2087 ISABELLE AVE		TELEPHONE:	(650) 345-3051
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Eva Zita and Olivia De Guzman		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff physically abusive to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Jeung interviewed staff.

Based on LPA Jeung's investigation, which included interviews with staff and residents, this allegation is determined to be unsubstantiated.

Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210618093002

FACILITY NAME:	OLIVIA'S CARE HOME		FACILITY NUMBER:	415600965
ADMINISTRATOR:	DE GUZMAN, OLIVIA		FACILITY TYPE:	740
ADDRESS:	2087 ISABELLE AVE		TELEPHONE:	(650) 345-3051
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Eva Zita and Olivia De Guzman		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff did not report incidents to licensing
- Residents eloped from the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Jeung interviewed staff.

Based on investigation by the Community Care Licensing Division of the CA Department of Social Services, which included interviews with staff and residents and review of client files, this allegation is determined to be unfounded. This means that the allegation could not have happened and/or is without a reasonable basis.

Elopement of a client on 10/15/19 was reported to CCLD as required. LPA is not aware of any other elopements, nor any other reportable incidents that were not reported to CCLD, as required.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4